Outcomes of Mesh Plug Repair for Open Inguinal Hernia Performed by Resident Surgeons: Safety and Significance

Technical Summary: Outcomes of Mesh Plug Repair for Open Inguinal Hernia Performed by Resident Surgeons

Problem Statement
The study addresses the tension between the increasing complexity of surgical techniques required of residents and the limited opportunities for hands-on practice due to working hour restrictions and patient safety concerns. While inguinal hernia repair is a fundamental procedure in general surgery, previous literature suggests that recurrence rates may be higher when performed by residents or young surgeons. The authors sought to determine if the Mesh Plug (MP) repair, a common technique in Japan, could be performed safely by residents under strict supervision without compromising patient outcomes (specifically recurrence and complication rates) and to investigate whether this early operative exposure influences residents' career choices toward surgical specialties.

Methodology
This retrospective cohort study was conducted at Hanyu General Hospital between April 1, 2020, and March 31, 2024. The study population included 267 patients with 296 inguinal hernia lesions. Patients with recurrent hernias or prior hernia repairs were excluded.

• Intervention and Training: Residents (defined as physicians in their first or second year post-national medical examination) underwent a structured training program prior to performing MP repairs. This included textbook study, instructional surgical videos, and a minimum of five sessions as a first assistant. Surgery was only permitted after the supervising surgeon (T.S.) subjectively judged the resident to have sufficient understanding. All resident-performed surgeries were conducted under the direct supervision of T.S.
• Surgical Technique: The study utilized Mesh Plug (Bard MP) or Iliopubic Tract (IPT) repair under general anesthesia. The procedure involved a 5-cm incision, identification of the hernia sac, inversion of the sac, insertion of the plug into the preperitoneal space, and fixation of the plug and onlay patch to the transversalis fascia and posterior wall.
• Study Groups: Patients were categorized into two groups based on the operating surgeon: the "Resident" group (47 lesions) and the "Surgical Staff" group (249 lesions).
• Data Collection and Analysis: Data collected included operative time, blood loss, complications (bleeding, hematoma, infection), recurrence (confirmed via ultrasound or CT within 1 year), and hospital stay. Statistical comparisons were made using the chi-squared test for categorical variables and the Mann–Whitney U test for continuous variables. Career path intentions were self-reported 6 months after the rotation.

Key Results

• Operative Volume: Residents performed 47 of the 296 repairs (16%).
• Recurrence Rates: There was no statistically significant difference in recurrence rates between the two groups. The resident group had a recurrence rate of 2.1%, compared to 2.4% for the surgical staff group (P = 0.91). Univariate analysis confirmed that the operator (resident vs. staff) was not a significant risk factor for recurrence.
• Complications: The overall postoperative complication rate was higher in the resident group (6.4%) compared to the staff group (1.6%), with a P-value of 0.05. Detailed analysis showed residents had higher rates of postoperative bleeding (2.1% vs. 0.4%) and hematoma (4.3% vs. 0.8%), though wound infection rates were lower (0% vs. 0.4%). These specific differences were not statistically significant individually.
• Operative Time: Residents required significantly longer operative times. The median time for residents was 59 minutes (IQR 29–91) compared to 30 minutes (IQR 15–69) for surgical staff (P < 0.01).
• Career Impact: Before the rotation, 6 of 18 residents (33.3%) intended to pursue a surgical specialty. After the rotation, this number increased to 9 of 18 (50%), with residents reporting that the experience deepened their anatomical understanding and provided a "thrill" of surgery that textbooks could not replicate.

Significance and Claims
The paper claims that with appropriate supervision and a structured educational framework involving surgical videos, residents can safely perform Mesh Plug repairs for inguinal hernias without increasing the risk of recurrence compared to experienced surgical staff. The authors emphasize that while operative times are longer and minor complication rates are slightly higher for residents, the procedure remains safe.

The study further suggests that early exposure to surgery through such training programs may positively influence residents' decisions to pursue surgical careers, potentially addressing the shortage of surgeons by fostering interest during the general training phase. The authors conclude that surgical videos are a valuable tool for pre-operative education, allowing residents to visualize procedural flow and practice mentally before entering the operating room.

Limitations
The authors acknowledge several limitations, including the retrospective, single-center nature of the study, potential selection bias, and the reliance on self-reported career data. Additionally, the 1-year follow-up period for recurrence may be insufficient to capture long-term outcomes, although the authors note that MP repair recurrences typically occur within the first year. The study also notes the lack of objective evaluation tools (e.g., checklists) for assessing resident readiness prior to surgery.